The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 227 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) medication management – controlled substances inspections, (2) coordination of care – hospice and palliative care, and (3) long-term home oxygen therapy. The facility’s reported accomplishment was the Palliative Care Program and the Nursing Evidence-Based Practice Scholar Program. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) nurse staffing, and (4) preventable pulmonary embolism.